Electrical
Stimulation UtilizationParameters
Definition of
Electrical Stimulation Therapy
Used in the Treatment of Urinary Incontinence or Other Voiding and Pelvic
Disorders.
Electrical stimulation
therapy can be considered a passive physiotherapy as opposed to patient
initiated or active therapeutic exercise of the pelvic floor (i.e. pelvic
muscle rehabilitation using biofeedback.). There is a twofold action of
electrical stimulation when applied to the pelvic floor:
2)
Relaxation
and inhibition of bladder activity (Kralj 1991).
The principle of
electrostimulation is based on the restoration of normal physiological reflex
mechanisms in abnormal nerves and muscles (Eriksen 1992). Electrodes can be placed externally (in the
vagina or rectum ) or internally implanted.
Methods of stimulation include
chronic (long-term continuous) and short term (in office or with home unit).
The experience with
electrical stimulation now encompasses thirty years and a very large number of
incontinent patients. Problems include
the fact that functional electrical stimulation does not belong to the therapeutic traditions in urology and
gynecology, there is a need of personal training for successful treatment and
there is a lack of systematic studies on different clinical applications. Significant advantages are a rational
physiological basis, applicability in a variety of lower urinary tract
dysfunctions, few side effects and a potential curative effect (Fall M, 1998). Although nearly all studies
of ES have been uncontrolled, a substantial body of “soft” data attests to
efficacy and safety of this technique.
(Appell RA, 1998) Strong
evidence to suggest electrostimulation is superior to sham
electrostimulation. (Berghmans
1998). Electrical stimulation has been
reported to be effective for stress incontinence with cure rates ranging from
30 -50% and improvement form 6 to 90% (Yamanishi, 1998).
Few studies address long
term effectiveness. In a small
uncontrolled study (Bratt, 1998) found after 10 years most of the participants
(n=27) had symptoms of urge
incontinence reported as a minor problem among a third of them and the majority
were satisfied with maximal stimulation as a treatment modality.
Medical
Necessity and Indications of Use
·
stress
incontinence
·
Urge
incontinence
·
Urinary
retention
·
Sensory
urgency
·
Dysuria
·
Dyspareunia
(scott 1979)
·
Interstitial
cystitis (fall 1980)
·
Vaginismus
(scott 1979)
·
Dysmenorrhea
(mannheimer 1985)
·
Documented
evidence of patient selection may also
include :
·
Lower
urinary tract dysfunctions in multiple sclerosis (vahtera 1997),
·
Post
radical prostatectomy (moore 1999) and
·
Spinal
cord lesions from C5 - T4 (Plevnik, 1984)
Factors to consider :
Patient age, presence of estrogen, absence of
Intrinsic Sphincter Deficiency (ISD), low urethral hypermobility,
compliance (Susset J 1995). Body mass index and patient compliance may affect
success (Miller 1998)
Contraindications
Anatomic changes (e.g. ectopic ureter, genitourinary
fistulas), on-demand pacemakers and pelvic organ prolapse, denervated pelvic
floor muscles, ISD and use during heavy menses.
Therapies
Suggested prior to use of Electrical
Stimulation
Based on present knowledge,
pelvic muscle exercise should be the first choice of treatment for stress
urinary incontinence. (Bo 1998) Bo also compared pelvic muscle exercises,
electrical stimulation, vaginal cones and no treatment for Genuine Stress
Incontinence (GSI). Training of the
pelvic floor muscles was found to be superior to electrical stimulation and vaginal
cones (Bo 1999). Medication therapy for
urge incontinence can provide cure or improvement in symptoms. However, medication therapy with known side
effects would be necessary long term for continued control of urge
incontinence.
Treatment
Options
Health care providers
trained to provide electrical stimulation agree that for stress incontinence a
high frequency, high amperage is most appropriate and for urge incontinence low
frequency and moderate amperage is used.
Maximal office electrical stimulation, home unit or sacral implant for
chronic stimulation may be chosen depending on the patient’s physical needs and
social factors. Treatment regiments
have been described as follows:
·
with
a home unit : qd 30 minutes (Bo 1999),
·
qod
via home unit (Siegal SW 1997) (Richardson DA 1996),
·
15
minutes BID or QOD X 20 weeks with home unit (Miller 1998),
·
chronic
treatment consisting of 1.5 -2 hours daily for 3 months with home unit (Kralj
1999)
·
a
minimum of 14 weeks necessary before significant objective improvements
were seen. (Miller,1998)
·
office
electrical stimulation: 6 sessions (Vahtera 1997)
·
6-10
biweekly office session followed by home unit BID X 6 weeks (Elgamasy 1996)
·
15
sessions 20 minutes duration in office
(Primus 1996)
·
12
sessions 20 minutes x6 weeks in office (Susset 1995)
The patient interactions
with an appropriately trained clinician during electrical stimulation therapy
will enhance outcomes. The following
interventions are included in a comprehensive office visit:
1)
reviewing
bladder diaries and toileting habits
2)
monitoring
bowel function
3)
reinforcing
strategies to use pelvic muscle contraction (via biofeedback) to prior to
episodes of increased abdominal pressure and to delay urgency and
4)
monitoring
fluid intake, and other dietary suggestions such as limiting caffeine intake
The exact schedule and use
of stimulation needs then to be tailored to the diagnosis, and the treatment
program depends heavily on monitoring the patient for response.
References:
Berghmans
LC, et al Conservative treatment of stress urinary incontinence in women: a
systematic review of randomized clinical trials. Br J Urol. 1998 Aug;82(2):181-91.
Bo K,
et al. Single blind, randomized controlled trial of pelvic floor exercises,
electrical stimulation, vaginal cones, and no treatment in management of
genuine stress incontinence in women.
BMJ. 1999 Feb 20;318(7182):487-93.
Bo, K.
Effect of electrical stimulation on stress and urge urinary incontinence.
Clinical outcome and practical recommendations based on randomized controlled
trials. Acta Obstet Gynecol Scand Suppl. 1998;168:3-11. Review.
Bower
WF et al. A urodynamic study of
surface neuromodulation versus sham in detrusor instability and sensory
urgency. J Urol. 1998 Dec;160(6 Pt 1):2133-6.
Bratt
H et al Long-term effects ten years after maximal electrostimulation of the
pelvic floor in women with unstable detrusor and urge incontinence. Acta Obstet Gynecol Scand Suppl.
1998;168:22-4.
Brown,
C. Pelvic floor rehabilitation: conservative treatment for incontinence. Ostomy
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Dahms
SE, et al. The impact of sacral root anatomy on selective electrical
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Egon G
et al. Implantation of anterior sacral root stimulators combined with posterior
sacral rhizotomy in spinal injury patients. World J Urol. 1998: 16 (5): 342-9.
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Moore KN,
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Moul
JW Pelvic muscle rehabilitation in males following prostatectomy. Urol Nurs. 1998 Dec;18(4):296-301. Review.
Palacio
MM, et al. Muscular urinary sphincter: electrically stimulated myoplasty for
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MW et al. Long-term efficacy of
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